Not a caring state at all

THIS is a remarkable book. In just 200-plus pages, it sums up everything that needs to be said about the health sector in Pakistan. It recalls its 50-year history, analyses the factors that have determined the state of the health of the nation, laments the grim statistics,sums up the changes that have taken place — for better or for worse — and makes useful recommendations. Of course, one has to be a die-hard optimist to believe that the sensible advice given by the author will actually be accepted by those who are in the corridors of power.
Dr Zaki Hasan, the author, is the founder of the neuropsychiatry department at the JPMC, Karachi, has worked on Unicef’s executive board and has been involved in the imparting of community-based medical education, being associated with two private medical colleges in Karachi. Also being a practising physician, he saw at close quarters the public health challenges in Pakistan.

The malaise in the health sector can be traced back to the age of colonisation when the imperial power subordinated all sectors of national life in their colonies to their commercial, political and administrative interests. In India, the British dealt a grievous blow to the practice of indigenous medicine and, instead, created a health care system that catered to a very small section of the population. The hospitals that were set up were for the ruling class and 90 per cent of the people had no access to them.

After the emergence of Pakistan in 1947, its rulers failed to change this pattern of health care. Faulty planning and corruption helped perpetuate a system that is most inequitable. The distribution of health delivery services is uneven, and this is reflected in the unequal burden of disease in society. The urban areas receive the preponderant share of funds and services, while women, the poor, the uneducated and the socially depressed suffer from ill health and are denied access to medical facilities.

The most painful aspect of the health scenario in Pakistan is that 60 per cent of the disease burden comprises illnesses that are preventable. They are either communicable diseases against which protection is possible or are illnesses caused by malnutrition, injuries or inadequate reproductive health care. The chapters on women’s health by Dr Sadiqua N. Jafarey, and diseases caused by environmental pollution, mental health and the development of health policies (written jointly with Siraj-ul-Haq Mahmud) shed light on these important aspects of public health in Pakistan.

Why is the situation so bleak? The author identifies some basic weaknesses that the health sector suffers from which have made it difficult to expand the health delivery network and adopt the strategies that are essentially needed. These are inadequate funding, manpower imbalances, inequitable distribution of services which have made the system ineffective. The strategies are inherently flawed. For instance, a centralised management, weak human resource development, negative staff attitude, lack of transparency and insufficient preventive intervention have made it difficult for the health managers to create a system that meets our needs.

While these weaknesses must be corrected without delay, there is also a need to recognise that, what the author terms, different phases of “health transition” have occurred in Pakistan which have led to a change in the health status of the people over a period of time. The main causative factors for these changes are the ageing of the population, increase in the diseases of affluence and environment, demand and misuse of high technology and the rising cost of health services.

The problems are so overwhelming that it needs courage to face them squarely and draw up an agenda for action. Dr Zaki Hasan proposes the reforms that should be undertaken if a beginning has to be made.

These are:

• Rationalising the role of the private sector

• Provision of primary health services

• Reducing waste

• Mobilising community involvement

• Reducing female morbidity

• Strengthening the NGOs and CBOs.

He admits that some changes are already under way. For instance, hospitals are getting more autonomy while the public sector hospitals have introduced users’ charges to recover some of the costs, the community-based health care providers have been linked with health outlets, the health management information system has been introduced and the private sector has been increasingly involved in the health delivery network.

But the country still has a long way to go as the health statistics show. Universal coverage — access to care and financial protection for all — is essential for improving the health status of Pakistanis. This calls for a sufficient supply of services and the removal of financial barriers to the provision of services. As the author points out, this has not been done in Pakistan. Dr Mubashir Hasan, a former finance minister in Z.A. Bhutto’s government and now a member of Pakistan-India Forum for Peace and Democracy, observes in the preface to the book: “The burden of health care for the vast majority of our population must be borne by the state. However, not only does the state in Pakistan lack the resources to fulfil its part of the social contract pertaining to the health sector but also, in matters of allocation of resources, it shows gross bias in favour of the rich and the salaried people.”

There are two subjects which should have received more intensive treatment and analysis. One is the corruption in the health sector that has undermined the existing services and drains away the funds that are allocated to the health budget. The other is the role of the pharmaceutical sector in pushing up the cost of treatment.